Britain’s “Dr Death,” a family physician who systematically murdered his patients, probably killed 250 people, an inquiry announced on Thursday after ruling the number of his victims was greater than originally thought.

The total confirms Dr Harold Shipman as the second-worst serial killer of recent times behind Colombian Pedro Lopez who was convicted of 57 murders in 1980 but is suspected of killing 300 young girls.

The bearded, bespectacled Shipman killed most of his victims with lethal heroin injections but never showed remorse or explained his motives. He hanged himself in prison a year ago on the eve of his 58th birthday.

A final report into Shipman’s crimes found he had murdered three patients while working as a junior hospital doctor in the 1970s, and was probably responsible for many more including that of a four-year-old girl.

These came before his notorious killing spree as a family practitioner when he murdered 215 mostly elderly patients and may have ended the lives of another 45.

“I estimate in all Shipman probably killed about 250 patients, of whom I have been able to positively identify 218,” inquiry head Judge Dame Janet Smith told reporters.

Shipman was convicted in 2000 of murdering 15 of his patients and sentenced to life in prison.

But police, relatives and colleagues always suspected he had committed more murders in his surgery and at patients’ homes in Hyde, near Manchester in northwest England.

A first public inquiry, launched after his conviction, studied the deaths of 500 patients over a 23-year period.

Smith had originally ruled that there had been no suspicious deaths while Shipman worked earlier in his career at Pontefract General Infirmary in northern England as a young doctor.

But an unnamed health official last year voiced suspicions and lawyers from the inquiry spent months tracking down relatives of 137 patients who had had their death certificates signed by Shipman while he was at Pontefract.

On Thursday the inquiry concluded Shipman was behind the deaths of three patients there and probably killed 10 to 15 more.

Smith said it meant Shipman had begun to kill patients possibly less than a year after leaving medical school.

“There is some evidence from which it would be reasonable to infer that Shipman was very interested in drugs and was willing to test their effects regardless of any risks to which the patient might be exposed,” Smith said

“It is possible, and I say no more, that in those early days Shipman killed by the reckless administration of drugs rather than with the positive calculated intention to kill which I’m satisfied was present later in his career.”